HomeMy WebLinkAboutBLDP-17-001997 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
rArail CITY v MA DATE PERMIT#/jI4P /7GV /Y97
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JOBSITE ADDRESS e-G. OWNER'S NAME Cl 5 4C) (1/I Ses,1
POWNER ADDRESS #Y444 / 5 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENTS PLANS SUBMITTED: YES❑ NO
FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER ,
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY Z
ROOF DRAIN _ _
SHOWER STALL
: SERVICE/MOP SINK _ T
TOILET ril, , 2
>... URINAL ^--
WASHING MACHINE CONNECTION _
W WATER HEATER ALL TYPES / _
WATER PIPING
1iii
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El---"NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY -� OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. \ n
PLUMBER'S NAME LICENSE# f /r/ SIGNATURE
MP❑ JP 65- CORPORATION ❑# PARTNERSHIP❑.# Lc❑# Pro P
COMPANY NAME C.j3 f! 4.4,
p-f-44 ADDRESS / MA+
CITY So q l41 01/1-6) STATE '"/4 ZIP TEL
TEL -)7 G 7-/0 y/7iZ
FAX CELL EMAIL 54i/i Jam. /►i 6 :, _,
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES